Chiara Zanchi

Bone Metabolism in Celiac Disease

OBJECTIVEnTo investigate the prevalence of both calcium metabolism alterations and bone defects in children with celiac disease (CD).nnnSTUDY DESIGNnWe studied 54 untreated patients with CD (mean age, 7 years). We compared the serum concentration of calcium, magnesium, 25(OH)vitamin D3, alkaline phosphatase, and parathyroid hormone (PTH) of patients with CD with those of 60 healthy children. Children with CD with 2 laboratory alterations underwent DEXA examination, which was evaluated after 6 months of a gluten-free diet (GFD).nnnRESULTSnThe calcium and the 25(OH)vitamin D3 levels were lower in children with CD than in control subjects, and the PTH level was higher in children with CD than in control subjects (P < .001). Hyperparathyroidism was found in 29 children with CD. Twenty patients tested positive for 2 laboratory alterations, and 10 of them were osteopenic. After 6 months of GFD calcium, 25(OH)vit.D3 and PTH levels normalized, with the improvement of bone mineral density.nnnCONCLUSIONSnCalcium metabolism defects are common in untreated children with CD, and they returned to normal after GFD. A detailed, time-consuming, and expensive study of bone metabolism is not necessary in children with CD shortly exposed to gluten who follow the GFD.

Compliance with the Gluten-Free Diet: The Role of Locus of Control in Celiac Disease

OBJECTIVESnTo verify whether subjects with celiac disease (CD) have a different locus of control (LoC) compared with healthy subjects, and to evaluate the relationship between LoC and compliance with a prescribed gluten-free diet (GFD) and quality of life (QoL).nnnSTUDY DESIGNnWe studied 156 subjects on a GFD (mean age, 10 years) and 353 healthy controls (mean age, 12 years). All subjects completed tests on the Nowicki-Strickland Locus of Control Scale; the subjects with CD also completed a questionnaire to measure compliance with dietary treatment and the diseases impact on QoL.nnnRESULTSnThere was no difference in LoC values between patients with CD and controls. Subjects with CD with good dietary compliance had a more internal LoC compared with those who were not compliant (P = .01). Patients who reported a satisfactory QoL had a more internal LoC compared with those who reported negative affects on QoL due to CD (P = .01).nnnCONCLUSIONSnOur study confirms the usefulness of the LoC concept for identifying those patients who might be at risk for dietary transgression. Given the enhanced, psychological, and social well being that can result from adherence to a GFD, educational and psychological support can help internalize the LoC in those patients at risk for dietary transgression.

Diagnostic accuracy of ultrasonography for hand bony fractures in paediatric patients

Objective Hand fractures are common in childhood, and radiography is the standard diagnostic procedure. US has been used to evaluate bone injuries, mainly in adults for long-bone trauma; there are only a few studies about hand fractures in children. The purpose of this study was to evaluate and confirm the safety and applicability of the US diagnostic procedure in comparison to X-ray diagnosis. Study design This cross-sectional study involved a convenience sample of young patients (between 2 and 17u2005years old) who were taken to the emergency department due to hand trauma. After clinical assessment, patients with a suspected hand fracture first underwent X-ray, and subsequently US examination by two different operators; a radiologist experienced in US and a trained emergency physician in “double-blind” fashion. US and radiographic findings were then compared, and sensitivity as well as specificity was calculated. Results A total of 204 patients were enrolled in the study. Seventy-nine fractures of phalanges or metacarpals were detected by standard radiography. When US imaging was performed by an expert radiologist, 72 fractures were detected with sensitivity and a specificity of 91.1% and 97.6%, respectively. Sensitivity and specificity were found to be (respectively) 91.5% and 96.8% when US was performed by the ED physicians. Conclusions US imaging showed excellent sensitivity and specificity results in the diagnosis of hand fractures in children. The study also showed a great agreement between the results of the US carried out by the senior radiologist and those carried out by the paediatric emergency physician, suggesting that US can be performed by an ED physician, allowing a rapid and accurate evaluation in ED and could become the first diagnostic approach whenever a hand fracture is suspected.

Rapid anti-transglutaminase assay and patient interview for monitoring dietary compliance in celiac disease

Abstract Objective. The anti-transglutaminase antibodies (anti-tTG) play an important role in monitoring the celiacs gluten-free diet (GFD). Material and methods. The authors propose to use the rapid IgA anti-tTG assay based on a whole blood drop to evaluate the compliance to GFD at the clinical ambulatory setting. The rapid test results were compared with those of the conventional ELISA assay and with dietary compliance reported by patients interview. Conclusions. The authors showed that anti-tTG rapid test is reliable and easy to perform in the ambulatory setting to evaluate dietary compliance. Moreover, they proved that celiacs interview is more sensitive than serology in identifying patients who transgress.

Normal saline flushes performed once daily maintain peripheral intravenous catheter patency: a randomised controlled trial

Objective Recent evidence supports the use of normal saline flushes in place of heparin to maintain the patency of peripheral intravenous locks (IVLs); however, there are no data regarding the recommended flush frequency. Study design This was an open, non-inferiority, randomised controlled trial. Children with IVLs, aged 1–17u2005years, were randomly assigned to receive saline flushing every 12u2005h (group A) or every 24u2005h (group B). The main outcome was the maintenance of catheter patency. Results Four hundred patients were randomised; 198 subjects were analysed in the 12u2005h group and 199 in the 24u2005h group (three patients were lost at follow-up). Occlusion occurred in 15 children (7.6%) in group A versus 9 (4.5%) in group B (p=0.21). The difference in catheter patency was +3.1% in favour of the 24u2005h group (95% CI −1.6% to 7.7%), showing the non-inferiority of the 24u2005h procedure (the non-inferiority margin was set at −4%). Catheter-related complications were not different between the two groups (12.1% in group A vs 9.5% in group B; p=0.42). Conclusions A flushing procedure with one flush per day allows maintenance of catheter patency without an increase in catheter-related complications. We propose a simplification of the flushing procedure with only one flush per day, thereby reducing costs (materials use and nursing time), labour and unnecessary manipulation of the catheters which can cause distress in younger children and their parents. Trial registration number The study is registered in the international database ClinicalTrial.gov under registration number NCT02221024.

Leonardo da vinci meets celiac disease

Background and Aim: Leonardo da Vincis face symmetry derives from 3 equal craniofacial segments: trichion-nasion (tn), which represents the superior third of the face, nasion-subnasal (ns) that is the medium third of the face, and subnasal-gnathion (sg) that is the length of the lower third of the face. It has been reported that adult subjects with celiac disease (CD) can be identified on the basis of a greater extension of the forehead in comparison to the medium third of the face, with a high tn/ns ratio. The aim of the present study was to investigate the correlation between facial asymmetry and CD in childhood and adulthood. Methods: We studied 126 biopsy-proven patients with CD (76 children and 50 adults) and 102 healthy controls (43 children and 59 adults). Their faces were photographed; the pictures were edited using a software program to calculate the facial segments. Results: The tn length was significantly different between adult celiac and adult controls (7.43u200a±u200a1.46 cm vs 6.38u200a±u200a1.73 cm, Pu200a=u200a0.001). The cutoff of 6.5 cm tn, derived from receiver operating characteristic curve analysis, identified 43 of 50 patients (sensitivity 86%), but 34 of 59 controls were positive (specificity 54.2%). The positive predictive value was 56%; however, the tn/ns ratio was not significantly different between celiacs and controls. Neither the tn length nor the tn/ns ratio in celiacs correlated to the time of gluten exposure. Conclusions: Adults, but not children, with celiac disease show a forehead extension significantly greater than controls, but this tests specificity appears too low to be used in the screening of CD.

Immunohistologic analysis of the duodenal bulb: a new method for celiac disease diagnosis in children

BACKGROUND AND AIMSnAnti-tissue transglutaminase antibodies (anti-tTG) have simplified celiac disease (CD) diagnosis. However, in atypical forms of CD, intestinal biopsy sampling is still required. This prospective study investigates whether histologic analysis of the duodenal bulb combined with intestinal IgA anti-tTG deposit immunoassay makes CD diagnosis possible in at-risk children with low concentrations of serum anti-tTG.nnnMETHODSnHistologic and intestinal IgA anti-tTG deposit immunoassays were used.nnnRESULTSnTwo hundred forty-five symptomatic children positive for serum anti-tTG (>7 U/mL) were enrolled andxa0divided into 3 groups: extensive duodenal atrophy (nxa0= 209), with IgA anti-tTG deposits throughout the duodenum and high serum anti-tTG concentrations (157 ± 178 U/mL); bulb duodenal atrophy (nxa0= 22), with widespread IgA anti-tTG deposits in 9 and in the bulb alone in 13 and low serum anti-tTG concentrations (13.9xa0± 8.7 U/mL); and normal duodenum (nxa0= 14), with widespread IgA anti-tTG deposits in 8 and in the bulb alone in 6 and low serum anti-tTG concentrations (10.6 ± 6.2 U/mL). All patients in the first 2 groups were diagnosed with CD and 8 from the third group. All improved after 1 year of gluten-free diet. Bulb duodenal analysis led to a 12% (30/245) increase in CD diagnosis. No CD-related lesions were observed in the 30 control subjects.nnnCONCLUSIONSnIn children at risk for CD, bulb duodenum biopsy sampling is essential to identify villous atrophy and detect IgA anti-tTG deposits even in absence of intestinal lesions. These mucosal autoantibodies could well represent a new standard for diagnosing CD.

Administering analgesia sublingually is a suitable option for children with acute abdominal pain in the emergency department

Acute abdominal pain is a frequent complaint in children attending emergency departments. The aim of this study was to investigate the pain score reductions when children with acute abdominal pain received medication sublingually.

A teenage girl with lower abdominal pain

A 14 year old girl arrived with her mother at the emergency department complaining of a 6 day history of lower abdominal pain, associated with dysuria and mild fever. She reported no other symptoms. On examination, the girl was tender across the lower abdomen, particularly in the right lower quadrant, where mild guarding and rebound tenderness were present. She was given intravenous paracetamol.nnDuring a brief private talk, she said she was sexually active with her boyfriend and was not using any form of contraception. Laboratory tests showed increased white blood count (13.6×109/L, neutrophils 8.7×109/L), C reactive protein of 5.4 mg/dL, and erythrocyte sedimentation rate of 47 mm/h. Beta-human chorionic gonadotropin levels were negative. Urine analysis showed mild leucocyturia.nnAn abdominal ultrasound showed normal appendix and ovaries, with a small amount of free pelvic fluid. Gynaecological physical examination showed cervical and uterine motion tenderness and vaginal discharge. A transvaginal ultrasound with colour Doppler analysis showed thickened, fluid filled fallopian tubes with hypervascularity (fig 1).nnnnFig 1(a) nUltrasound image shows tubes with thick walls and intraluminal fluid nnnnnnFig 1(b) nColour Doppler shows increased vascularity of the tubennnnnn### 1. What is the most likely diagnosis?nn#### Short answernnA clinical presumptive diagnosis of pelvic inflammatory disease was made according to the diagnostic criteria stated by the 2015 Centers for Disease Control and Prevention guidelines for pelvic inflammatory disease.12345nn#### DiscussionnnPelvic inflammatory disease should be suspected in any sexually active adolescent girl presenting with a persistent …